Georg Marckmann and Corinna Klingler, Institute for Ethics, History and Theory of Medicine, Ludwig-Maximilians-University Munich; Jürgen in der Schmitten, Institute for General Practice, Heinrich-Heine University of Düsseldorf, Germany, explain the background to their longer article selected as Editor’s Choice in the May edition of Palliative Medicine.

Jürgen in der Schmitten, Corinna Klingler and Georg Markmann

There is increasing empirical evidence that Advance Care Planning (ACP) is indeed able to reach its primary goal: strengthen patient autonomy and improve quality of care near the end of life. Given the steeply rising costs for life-sustaining treatment before death, it is somewhat surprising that there is only little debate and scattered empirical evidence about the effects of comprehensive ACP-programmes on the costs of care. We therefore conducted a systematic review of the cost implications of facilitated Advance Care Planning, which has just been published in Palliative Medicine. So for this review, we understood ACP in its historical, proper sense (defined by a qualified conversational process between a facilitator and the individual). We consequently ignored conventional advance directives (ADs) that may or may not be based on such a process, even though nowadays some authors call anything that leads to an AD, Advance Care Planning.

Our systematic search in five relevant data bases confirmed our initial impression: There is only limited, heterogeneous and methodologically not very rigorous evidence on the cost implications of ACP comprising at least one professionally facilitated conversation about future care. However, six out of the seven studies that were included in this review demonstrated cost savings through ACP. If mentioned, programme costs were comparatively small amounting to less than 15% of the overall savings. However, no study accomplished a comprehensive approach covering all direct and indirect costs of the intervention.

This – preliminary – evidence makes ACP an attractive tool for funders and policymakers: Where else in our technologically driven healthcare systems is it possible to improve quality of care and reduce costs substantially at the same time? What appears to be an ethical no-brainer at first glance turns out to be more delicate at a closer look: ACP programmes only reduce costs if patients opt for limiting life-sustaining treatment. Under the current economic pressure in most healthcare systems, ACP facilitators could be incentivised to advise individuals to choose less invasive and therefore less costly treatment in their ADs.

These conflicts of interest could jeopardise the openness of the communication process – one, if not the, central feature of ACP! – and may erode patient trust in ACP. This is not a hypothetical fear: Sarah Palin’s “death panel” rhetoric was successful in creating sufficient political pressure in the US to turn down the Medicare reimbursement for ‘Advance Care Planning Consultations’ in the Affordable Health Care Choices Act in 2009.

We conclude: ACP must remain an intervention aiming exclusively at ensuring that patients’ wishes are honoured reliably when they have lost decision-making capacity. It is good to know that the considerable investment necessary for a regional implementation of ACP, especially in the early years, is likely to be offset by financial gains, at least in the long run. However, it would be naïve not to take into account that cost containment is an important driver for funders and policymakers. In our paper, we therefore propose several safeguards to ensure the openness of ACP – above all, clearly defined and supervised quality standards for the facilitation process.

Read the full article in Palliative MedicineThis blog post relates to the longer article, ‘Does facilitated Advance Care Planning reduce the costs of care near the end of life? Systematic review and ethical consideration’ by Corinna Klingler, Jürgen in der Schmitten and Georg Marckmann, Palliat Medicine May 2016 vol. 30 (5) 423-433. Published online before print August 20, 2015, doi: 10.1177/0269216315601346.

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